Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nursing is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care?
A. Place the client in protective isolation.
Protective isolation is not routinely required for clients following scoliosis repair unless there is an underlying infection risk.
B. Initiate the use of a PCA pump for pain control.
A PCA pump may be used for pain control, but it is not specific to post-scoliosis repair care.
C. Keep the head of the bed at a 30° angle.
Keeping the head of the bed at 30° is not required; positioning should focus on spinal alignment.
D. Reposition the client by log rolling every-4 hr.
Log rolling the client every 4 hours is essential to maintain spinal alignment, prevent complications, and ensure safety following Harrington rod instrumentation.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 6. Take the full exam now
Full Explanation
A. Protective isolation is not routinely required for clients following scoliosis repair unless there is an underlying infection risk.
B. A PCA pump may be used for pain control, but it is not specific to post-scoliosis repair care.
C. Keeping the head of the bed at 30° is not required; positioning should focus on spinal alignment.
D. Log rolling the client every 4 hours is essential to maintain spinal alignment, prevent complications, and ensure safety following Harrington rod instrumentation.
Similar Questions
A nurse is preparing to administer a continuous heparin infusion at 1600 units/hr. Available is heparin 25.000 units in dextrose 5% in water (DSW) 500 mL. The nurse should set the IV pumpto deliver how many mL/hr?
(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
- To calculate the infusion rate, use the formula: mL/hr = (units/hr) x (mL) / (units) - Plug in the values from the question: mL/hr = (1600 units/hr) x (500 mL) / (25.000 units) - Simplify and solve: mL/hr = 32
- Round to the nearest whole number: 32
- The answer is 32 mL/hr
A nurse is assessing the elastic bandage on the stump of a client who had a right below-the knee amputation. Which of the following findings should the nurse identify as a complication?
A. Looseness of the stump dressing
Looseness of the stump dressing may indicate the need for adjustment, but it is not a complication in itself.
B. The dressing forms a cone shape over the stump
The dressing forming a cone shape over the stump is a not sign of complications.
C. Pitting edema around the stump dressing
Pitting edema around the stump dressing may indicate swelling, which is common after an amputation. It is important to monitor for excessive edema as it is a sign of potential complication.
D. Figure-eight wrapping around the stump
Figure-eight wrapping around the stump is a technique used to provide even pressure and support, helping to prevent edema and promote healing. It is not a complication.
Full Explanation
A. Looseness of the stump dressing may indicate the need for adjustment, but it is not a complication in itself.
B. The dressing forming a cone shape over the stump is a not sign of complications.
C. Pitting edema around the stump dressing may indicate swelling, which is common after an amputation. It is important to monitor for excessive edema as it is a sign of potential complication.
D. Figure-eight wrapping around the stump is a technique used to provide even pressure and support, helping to prevent edema and promote healing. It is not a complication.
A nurse is providing teaching for a client who is postoperative following below-the-knee amputation. The nurse should instruct the client that which of the following nutrients is necessary for would healing?
A. Vitamin B
Vitamin B is a group of vitamins that play various roles in the body, including energy metabolism and nerve function. While it is important for overall health, it is not specifically known for wound healing.
B. Vitamin E
Vitamin E is an antioxidant that helps protect cells from damage. While it is important for overall health, it is not specifically known for wound healing.
C. Folate
Folate (also known as vitamin B9) is essential for DNA synthesis and repair, as well as cell division. It is important for overall health, but it is not as directly associated with wound healing as vitamin C.
D. Vitamin C
Correct. Vitamin C, also known as ascorbic acid, is essential for collagen synthesis, which is a key component of wound healing. It helps in the formation of scar tissue and the repair of damaged skin.
Full Explanation
A. Vitamin B is a group of vitamins that play various roles in the body, including energy metabolism and nerve function. While it is important for overall health, it is not specifically known for wound healing.
B. Vitamin E is an antioxidant that helps protect cells from damage. While it is important for overall health, it is not specifically known for wound healing.
C. Folate (also known as vitamin B9) is essential for DNA synthesis and repair, as well as cell division. It is important for overall health, but it is not as directly associated with wound healing as vitamin C.
D. Correct. Vitamin C, also known as ascorbic acid, is essential for collagen synthesis, which is a key component of wound healing. It helps in the formation of scar tissue and the repair of damaged skin.